Background: While geographic disparities in stroke mortality are well documented, there are no data describing geographic variation in recurrent stroke. Accordingly, we evaluated geographic variations in 1-year recurrent ischemic stroke rates in the USA with adjustment for patient characteristics. Methods: One-year recurrent stroke rates for ischemic stroke (International Classification of Diseases, 9th Revision codes 433, 434 and 436) following hospital discharge were calculated by county for all fee-for-service Medicare beneficiaries from 2000 to 2002. The rates were standardized and smoothed using a bayesian conditional autoregressive model that was risk-standardized for patients’ age, gender, race/ethnicity, prior hospitalizations, Deyo comorbidity score, acute myocardial infarction, congestive heart failure, diabetes, hypertension, dementia, cancer, chronic obstructive pulmonary disease and obesity. Results: The overall 1-year recurrent stroke rate was 9.4% among 895,916 ischemic stroke patients (mean age: 78 years; 56.6% women; 86.6% White, 9.7% Black and 1.2% Latino/Hispanic). The rates varied by geographic region and were highest in the South and in parts of the West and Midwest. Regional variation was present for all racial/ethnic subgroups and persisted after adjustment for individual patient characteristics. Conclusions: Almost 1 in 10 hospitalized ischemic stroke patients was readmitted for an ischemic stroke within 1 year. There was heterogeneity in recurrence patterns by geographic region. Further work is needed to understand the reasons for this regional variability.
© 2010 S. Karger AG, Basel
- Stroke, recurrent
- Small-area analysis
- Variation, geographic
- Lloyd-Jones D, Adams R, Carnethon M, et al: Heart disease and stroke statistics – 2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2009;119:480–486.
- Samsa GP, Bian J, Lipscomb J, et al: Epidemiology of recurrent cerebral infarction: a Medicare claims-based comparison of first and recurrent strokes on 2-year survival and cost. Stroke 1999;30:338–349.
- Pickle LW, Mungiole M, Gillum RF: Geographic variation in stroke mortality in Blacks and Whites in the United States. Stroke1997;28:1639–1647.
- Lanska DJ, Kryscio R: Geographic distribution of hospitalization rates, case fatality, and mortality from stroke in the United States. Neurology 1994;44:1541–1550.
- El-Saed A, Kuller LH, Newman AB, et al: Geographic variations in stroke incidence and mortality among older populations in four US communities. Stroke 2006;37:1975–1979.
- Casper M, Nwaise I, Croft J, et al: Atlas of Stroke Hospitalizations among Medicare Beneficiaries. Atlanta, US Department of Health and Human Services, Centers for Disease Control and Prevention, 2008.
- Deyo RA, Cherkin DC, Ciol MA: Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992;45:613–619.
- Coull AJ, Rothwell PM: Underestimation of the early risk of recurrent stroke: evidence of the need for a standard definition. Stroke 2004;35:1925–1929.
- Sarti C, Stegmayr B, Tolonen H, et al: Are changes in mortality from stroke caused by changes in stroke event rates or case fatality? Results from the WHO MONICA Project. Stroke 2003;34:1833–1840.
- Bonita R, Anderson CS, Broad JB, et al: Stroke incidence and case fatality in Australasia: a comparison of the Auckland and Perth population-based stroke registers. Stroke 1994;25:552–557.
- Hill ME, Rosenwaike I: The Social Security Administration’s Death Master File: the completeness of death reporting at older ages. Soc Secur Bull2001;64:45–51.
- Besag J, York J, Mollie A: Bayesian image restoration, with two applications in spatial statistics. Ann Inst Stat Math 1991;43:1–59.
- Lunn D, Thomas A, Best N, Spiegelhalter D: WinBUGS – a Bayesian modelling framework: concepts, structure, and extensibility. Stat Comput 2000;10:325–337.
- Petty GW, Brown RD Jr, Whisnant JP, et al: Survival and recurrence after first cerebral infarction: a population-based study in Rochester, Minnesota, 1975 through 1989. Neurology 1998;50:208–216.
- Sacco RL, Shi T, Zamanillo MC, et al: Predictors of mortality and recurrence after hospitalized cerebral infarction in an urban community: the Northern Manhattan Stroke Study. Neurology 1994;44:626–634.
- Eriksson SE, Olsson JE: Survival and recurrent strokes in patients with different subtypes of stroke: a fourteen-year follow-up study. Cerebrovasc Dis 2001;12:171–180.
- Lisabeth LD, Smith MA, Brown DL, et al: Ethnic differences in stroke recurrence. Ann Neurol 2006;60:469–475.
- Matsumoto N, Whisnant JP, Kurland LT, et al: Natural history of stroke in Rochester, Minnesota, 1955 through 1969: an extension of a previous study, 1945 through 1954. Stroke 1973;4:20–29.
- Sacco RL, Wolf PA, Kannel WB, et al: Survival and recurrence following stroke. The Framingham Study. Stroke1982;13:290–295.
- Ostchega Y, Dillon CF, Hughes JP, et al: Trends in hypertension prevalence, awareness, treatment, and control in older U.S. adults: data from the National Health and Nutrition Examination Survey 1988 to 2004. J Am Geriatr Soc 2007;55:1056–1065.
- Moroney JT, Bagiella E, Paik MC, et al: Risk factors for early recurrence after ischemic stroke: the role of stroke syndrome and subtype. Stroke 1998;29:2118–2124.
- Hillen T, Coshall C, Tilling K, et al: Cause of stroke recurrence is multifactorial: patterns, risk factors, and outcomes of stroke recurrence in the South London Stroke Register. Stroke 2003;34:1457–1463.
- Ruland S, Richardson D, Hung E, et al: Predictors of recurrent stroke in African Americans. Neurology 2006;67:567–571.
- Gillum RF, Ingram DD: Relation between residence in the southeast region of the United States and stroke incidence. The NHANES I Epidemiologic Follow-Up Study. Am J Epidemiol 1996;144:665–673.
- Howard G: Why do we have a stroke belt in the southeastern United States? A review of unlikely and uninvestigated potential causes. Am J Med Sci 1999;317:160–167.
- Perry HM, Roccella EJ: Conference report on stroke mortality in the southeastern United States. Hypertension 1998;31:1206–1215.
- Howard G, Prineas R, Moy C, et al: Racial and geographic differences in awareness, treatment, and control of hypertension: the Reasons for Geographic and Racial Differences in Stroke Study. Stroke 2006;37:1171–1178.
- Voeks JH, McClure LA, Go RC, et al: Regional differences in diabetes as a possible contributor to the geographic disparity in stroke mortality: the Reasons for Geographic and Racial Differences in Stroke Study. Stroke 2008;39:1675–1680.
- Cushman M, Cantrell RA, McClure LA, et al: Estimated 10-year stroke risk by region and race in the United States: geographic and racial differences in stroke risk. Ann Neurol 2008;64:507–513.
- Tirschwell DL, Longstreth WT Jr: Validating administrative data in stroke research. Stroke 2002;33:2465–2470.
- Leibson CL, Naessens JM, Brown RD, et al: Accuracy of hospital discharge abstracts for identifying stroke. Stroke 1994;25:2348–2355.
- Fisher ES, Whaley FS, Krushat WM, et al: The accuracy of Medicare’s hospital claims data: progress has been made, but problems remain. Am J Public Health 1992;82:243–248.
- Benesch C, Witter DM Jr, Wilder AL, et al: Inaccuracy of the International Classification of Diseases (ICD-9-CM) in identifying the diagnosis of ischemic cerebrovascular disease. Neurology 1997;49:660–664.
- Kiyota Y, Schneeweiss S, Glynn RJ, et al: Accuracy of Medicare claims-based diagnosis of acute myocardial infarction: estimating positive predictive value on the basis of review of hospital records. Am Heart J 2004;148:99–104.
- Quan H, Li B, Saunders LD, et al: Assessing validity of ICD-9-CM and ICD-10 administrative data in recording clinical conditions in a unique dually coded database. Health Serv Res 2008;43:1424–1441.
- Williams GR: Incidence and characteristics of total stroke in the United States. BMC Neurol 2001;1:2.
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Received: July 12, 2009
Accepted: November 10, 2009
Published online: January 13, 2010
Number of Print Pages : 7
Number of Figures : 2, Number of Tables : 2, Number of References : 36
Additional supplementary material is available online - Number of Parts : 1
Vol. 34, No. 2, Year 2010 (Cover Date: February 2010)
Journal Editor: Feigin V.L. (Auckland)
ISSN: 0251-5350 (Print), eISSN: 1423-0208 (Online)
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